Heading
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date available to start
-
Month
-
Day
Year
Date
Social Security Number
Desired Salary
Position applying for?
US Citzen
Yes
No
Authorized to work in US?
Yes
No
Have you been placed on the EDL?
Yes
No
Type a question
If so why?
Have you ever been convicted of a felony?
Yes
No
Have you ever been convicted or plead guilty of a misdemeanor?
Yes
No
Have you had a suspended imposition of sentence, any suspended execution of sentence or any period of probation or parole?
Yes
No
If yes to any of the questions, please explain.
Education
High School
Address
Dates (From/To)
Degree
Did you graduate?
Yes
No
College
Date (From/To)
Did you graduate?
Yes
No
Degree
References (Please list three professional references.)
Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name
First Name
Last Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment History
Company
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Dates (From/To)
Reason for leaving
May we contact your previous employer for a reference?
Yes
No
Company
Phone Number
Please enter a valid phone number.
Supervisor
Job Title
Responsibilities
Date (From/To)
Reason for leaving
Military Service
Branch
Date
-
Month
-
Day
Year
Date
Disclaimer and Signature I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature
Date
-
Month
-
Day
Year
Date
Employee Non-Disclosure Agreement Extend A Hand Directed Care, LLC fully understands the importance of confidentiality. Therefore, all employees with access to company, client and employee information to include but not limited to personal and medical information are required to sign this form. All information obtained while working for EAHDC shall be kept confidential. No personal commuters, cellular phones, or cameras should be used while working with clients. Information should only be given out on a need-to-know basis that is approved by the supervisor. Employees of EAHDC will not at any time directly or indirectly disclose any information regarding business matters conducted by the company to include any information about the company, their employees, or any of their clients. No personal computers, cameras, or cellular phones will be used to take pictures of clients or any of their personal information unless otherwise authorized by the owner with a written consent signed by the client and supervisor. EAHDC will not tolerate any breach in contract. If a breach is determined EAHDC has the right to terminate the employee, and any other punishment deemed necessary. In signing this document, you are agreeing to the terms and conditions.
Signature
Date
-
Month
-
Day
Year
Date
Extend A Hand Directed Care Application for employment Consent for pre employment criminal record check.
Do you consent to a closed record check pursuant to Section610.120, RSMO
Yes
No
Do you consent to a pre employment criminal record check?
Yes
No
Please Disclose all criminal convictions, findings of guilt, pleadings of guilt, and pleadings of nolo contendere except minor traffic offenses.
By signing this form, you are confirming all information is true to the best of your knowledge.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
EAHDC Authorization for Background Screening (FSCR, EDL, Employment, and References)
Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application.
Name
First Name
Last Name
By signing this form, you are giving EAHDC permission to investigate your background and qualification for purposes of evaluating whether you are qualified for the position for which you are applying for. You understand that EAHDC may utilize an outside firm or firms to assist in checking such information, and you authorize such an investigation by information services and outside entities of the company's choice. You also understand that you may withhold permission and that in such a case, no investigation will be done, and your employment application will not be processed further.
Name
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
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